Tumors of the Penis

CURTIS A. PETTAWAY DONALD F. LYNCH, Jr, JOHN W.DAVIS

QUESTIONS
1. Which of the following penile lesions does NOT have malignant
potential?
a.
b.
c.
d.
e.

Balanitis xerotica obliterans

Condylomata acuminata
Coronal papillae
Bowen's disease
Leukoplakia

2. Which of the following infections is associated with cervical

dysplasia?

a. HIV infection
b. Herpesvirus infection
c. Gonorrhea
d. Human papillomavirus (HPV) infection
e. Lymphogranuloma venereum

3. What is the major difference between Bowen's disease and

erythroplasia of Queyrat?
a. Loss of rete pegs
b. Keratin staining
1
c. Viral etiologic agents
d. Location
e. Potential for metastasis
4. Kaposi's sarcoma of the AIDS-related (epidemic) type is
associated with which of the following etiologic agents?
a.
b.
c.
d.
e.

HPV type 16
Human herpesvirus (HHV) type 8
HPV type 32
Haemophilus ducreyi (chancroid [soft chancre])
Coxsackievirus type 23

5. Where do penile cancers most commonly arise?

a.
b.
c.
d.
e.

Glans
Shaft
Frenulum
Coronal sulcus
Scrotum

6. Which of the following is not considered a risk factor for the

development of squamous penile cancer?
a. Cigarette smoke
b. HPV infection
c. Phimosis

d. Gonorrhea
e. Chewing tobacco
7. All of the following are preventive strategies to decrease the
incidence of penile cancer EXCEPT which one?
a. Circumcision after 21 years of age g
b. Avoiding sexual promiscuity
c. Daily genital hygiene
d. Avoiding cigarette smoke
e. Circumcision before puberty
8. Which of the following statements regarding penile cancer is
FALSE?
a. Cancer may develop anywhere on the penis.
b. Because of the associated discomfort, patients usually
present to physicians within the first month of noting the
lesion.
c. Phimosis may obscure the nature of the lesion.
d. Penetration of Buck's fascia and the tunica albuginea by the
tumor permits invasion of the vascular corpora.
e. Cancer cells reach the contralateral inguinal region because
of lymphatic cross-communications at the base of the penis.
9. Before a treatment plan for penile cancer is initiated, which of
the following is TRUE?
a. Adequate biopsies to determine stage are unimportant,
because all patients should be treated with amputation.
b. Radiologic studies play no role in decision making.
c. DNA flow cytometry should be performed on virtually all
specimens, because it provides crucial information.
d. Tumor stage and grade and vascular invasion status all
provide prognostically important information.
e. No disfiguring therapy is indicated, because spontaneous
remissions have been noted in approximately 10% of cases.
10. Which of the following statements is TRUE regarding the
natural history of penile cancer?
a. Metastasis from the primary tumor often involves lung,
liver, or bone as initial sites.
b. Lymphatic drainage from the primary tumor is ipsilateral
alone in most cases.
c. Metastasis often initially involves spread from the corpora
cavernosa to the pelvic lymph nodes.
d. Metastasis initially involves inguinal lymph nodes beneath
the fascia lata.
e. Metastasis initially involves inguinal lymph nodes above
the
fascia lata.
.

Which of the following statements concerning hypercalcemia in

itients with penile cancer is TRUE?
E It is more commonly due to massive bone metastases than

bulky soft tissue metastases. !), It is often related to uremia

due to ureteral obstruction, c. It may be due to the action of
parathyroid hormone-like
substances released from the tumor, jl It is related to the action of
osteoblasts on bone formation. I It is managed with aggressive
diuretic administration as first-line therapy.
The following statements are true regarding imaging tests in
jtients with penile cancer EXCEPT which one?
Both ultrasonography and MRI lack sensitivity for the
detection of corpus cavernosum involvement.
I b. CT is not an appropriate test for determining primary
II tumor stage.
c. CT maybe beneficial in detecting enlarged inguinal nodes in
I:' obese patients or those who have had prior inguinal therapy.
I d. Lymphangiography can detect abnormal architecture in I
normal-sized lymph nodes. I e. Inguinal palpation is preferred
to CT and
lymphangiography for determining inguinal nodal status.
. According to the current 1997 version of the International
Union Against Cancer/TNM staging system for penile cancer,
which of the following statements is TRUE?
I a. Primary tumor stage is based on the size of the primary

lesion. ' :b. Lymph node stage is based on the resectability of

involved nodes.
c. Stage T2 tumors are based on biopsy and involve corpora
cavernosa only.
d. Large verrucous carcinomas are considered stage Ta.
e. Stage Tl tumors may involve the urethra at the meatus.
. What is the strongest prognostic factor for survival in penile
cancer?
a.
b.
c.
d.
e.

The presence of lymph node metastasis

^Tj
The grade of the primary tumor
The stage of the primary tumor
The vascular invasion present in the primary tumor
The extent of lymph node metastasis

, Criteria for curative surgical resection (>70% 5-year survival) in

patients treated for lymph node metastasis include all of the'
following EXCEPT which one?
a.
b.
c.
d.
e.

No more than two positive inguinal lymph nodes

No positive pelvic lymph nodes
Absence of extranodal extension of cancer
Unilateral metastasis
A single metastasis of only 6 cm

V
. Surgical staging of the inguinal region is strongly considered
under all of the following conditions EXCEPT which one?
a. Palpable adenopathy
b. Stage T2 or greater primary tumor
c. Presence of vascular mvasion in primary tumor
d. Presence of predominantly high-grade cancer in primary
tumor
e. Stage Ta tumors
A watchful waiting strategy toward the management of the
inguinal region in patients with no palpable adenopathy is
recommended for all of the following situations EXCEPT which
one?
a.
b.
c.
d.

Primary tumor stage Tis

Primary tumor stage Ta
Primary tumor stage Tl, grade I
Primary tumor stage Tl, grade II

e. Noncompiiant patients
18. Strategies to minimize the morbidity of inguinal staging in
patients with no palpable adenopathy include all the following
EXCEPT which one?
a.
b.
c.
d.
e.

Superficial inguinal lymph node dissection

Modified complete inguinal dissection
Standard ilioinguinal dissection
Sentinel lymph node biopsy
Intraoperative lymphatic mapping

19. Which of the following inguinal staging procedures is

considered
the 'gold standard' for detecting microscopic metastases while
limiting both morbidity and false negative findings?
a. Inguinal node biopsy
^ b. Superficial inguinal dissection
c. Sentinel lymph node dissection
d. Fine-needle aspiration cytology
e. Sentinel lymph node biopsy
20. For patients with proven unilateral metastasis all of the
following surgical considerations are true EXCEPT which one?
a. Ipsilateral ilioinguinal lymphadenectomy should be
performed.
b. A contralateral staging procedure is not indicated.
c. A contralateral staging procedure is indicated.
d. Both a superficial dissection and deep ipsilateral dissection
are performed.
e. Ipsilateral pelvic dissection provides useful prognostic
information.
21. Adjuvant or neoadjuvant chemotherapy should be considered in
addition to surgery for all of the following EXCEPT which one?
a.
b.
c.
d.
e.

Single pelvic nodal metastasis

Extranodal extension of cancer
Fixed inguinal masses
Two unilateral inguinal nodes with focal metastases
Single 6-cm inguinal lymph node

22. The majority of penile cancers are of which of the following

histologic types?
^ a. Melanoma
*
b. Bowenoid papulosis
c. Squamous cell carcinoma
d. Epidemic Kaposi's sarcoma
e. Verrucous carcinoma
23. Which of the following chemotherapeutic agents have been
used in combination therapy for penile cancer?
a. Bleomycin Q
b. Methotrexate
c. Cisplatin
d. 5-Fluorouracil (5-FU)
e. All of the above
24. Indications for radiation therapy as primary treatment for
penile cancer include which of the following?
a. Young, sexually active patient with a small lesion
b. Patient refuses surgery
$ c. Patient with inoperable tumor who needs local treatment but
desires to retain the penis
d. None of the above
e. a, b, and c
25. Primary penile melanoma is thought to be rare for what
reason?
a.
b.
c.
d.

Penile skin is protected from exposure to the sun.

Keratin content in penile skin is decreased.
Penile blood supply precludes such tumor development.
Effective topical chemotherapy exists.

e. None of the above

26. Lymphomatous infiltration of the penis is most likely
secondary to which condition?
a.
b.
c.
d.
e.

Autoimmune disorder
Diffuse disease
Metastasis from a distant primary tumor
Chronic infection
Previous venereal infection

27. What is the most frequently encountered sign of metastatic

involvement of the penis?
a. Pain
b. Urethral
discharge
pj c. Ecchymoses
d. Priapism
e. Preputial swelling
28. Which of the following features of Buschke-Lowenstein
tumor
characterizes it as different from condyloma acuminatum?
a. Propensity for early distant metastasis
b. Disruption of the rete pegs
c. Loss of pigmentation
d. Autoamputation
e. Invasion and destruction of adjacent tissue by
compression
29. Which of the following statements about how verrucous
carcinoma of the penis differs from classic BuschkeLowenstein
tumor is TRUE?
a. The terms describe the same disease.
b. Verrucous carcinoma sometimes exhibits spontaneous
regression.
c. Proportion of melanin pigment in verrucous carcinoma is
higher than in Buschke-Lowenstein tumor.
d. Simultaneous bilateral inguinal metastases occur
commonly
with Buschke-Lowenstein tumor.
e. Circumcision is not protective for verrucous carcinoma.
30. Small lesions of erythroplasia of Queyrat may be successfully
treated by which of the following?
a. Topical 5% 5-FU ^ b. Neodymium: yttrium-aluminumgarnet (Nd:YAG) laser
c. Local excision
d. External-beam radiation therapy
e. All of the above

ANSWERS

1. c. Coronal papillae. Coronal papillae present as linear, curved, or

irregular rows of conical or globular excrescences, varying from

white to yellow to red, arranged along the coronal sulcus. They are
considered acral angiofibromas. These lesions have not been
associated with malignancy.

2. d. Human papillomavirus (HPV) infection. HPV is recognized as

the principal etiologic agent in cervical dysplasia and cervical
cancer.

histologic grade of the lesion by microscopic examination of a

biopsy specimen are mandatory before the initiation of any
therapy.

10.

e. Metastasis initially involves inguinal lymph nodes

above the fascia lata. The lymphatics of the prepuce form a
connecting network that joins with the lymphatics from the
skin of the shaft. These tributaries drain into the superficial
inguinal nodes (the nodes external to the fascia lata).

3. d. Location. Carcinoma in situ of the penis is referred to by

11.

4. b. Human herpesvirus (HHV) type 8. HHV type 8also known as

12.

urologists and dermatologists as erythroplasia of Queyrat if it

involves the glans penis, prepuce, or penile shaft and as Bowen's
disease if it involves the remainder of the genitalia or perineal
region.
KSHV (Kaposi sarcoma-associated herpesvirus)is strongly
suspected to be the etiologic agent of epidemic (AIDS-related)
Kaposi sarcoma.

5. a. Glans. Penile tumors may present anywhere on the penis but

occur most commonly on the glans (48%) and prepuce (21%).

6. d. Gonorrhea. No convincing evidence has been found linking

penile cancer to other factors such as occupation, other venereal

diseases (gonorrhea, syphilis, herpes), marijuana use, or alcohol
intake.

7. a. Circumcision after 21 years of age. Adult circumcision appears

to offer little or no protection from subsequent development of the

disease. These data suggest that the crucial period of exposure to
certain etiologic agents may have already occurred at puberty and
certainly by adult age, rendering later circumcision relatively
ineffective as a prophylactic tool for penile cancer.

8. b. Because of the associated discomfort, patients usually present

to physicians within the first month of noting the lesion. Patients

with cancer of the penis, more than patients with other types of
cancer, seem to delay seeking medical attention. In large series,
from 15% to 50% of patients have been noted to delay medical care
for more than a year.

9. d. Tumor stage and grade and vascular invasion status all

provide prognostically important information. Confirmation

of the diagnosis of carcinoma of the penis and assessment of the
depth of invasion, the presence of vascular invasion, and

c. It may be due to the action of parathyroid hormonelike substances released from the tumor. Parathyroid
hormone and related substances may be produced by both
tumor and metastases that activate osteoclastic bone
resorption.
a. Both ultrasonography and MRI lack sensitivity for
the detection of corpus cavernosum involvement. The
sensitivity of ultrasonography for detecting cavernosum
invasion was 100% in one study. This study confirmed the
value of ultrasonography in assessing the primary tumor also
reported by other investigators. For lesions suspected of
invading the corpus cavernosum, both ultrasonography and
contrast medium-enhanced MRI may provide unique
information, especially when organ-sparing surgery is
considered.

13.

d. Large verrucous carcinomas are considered stage Ta.

According to this staging system, designations for primary
tumors are as follows: Tx indicates that the primary tumor
cannot be assessed; TO indicates no evidence of tumor; Tis
indicates carcinoma in situ; Ta indicates noninvasive verrucous
carcinoma; Tl indicates tumor invading subepithelial
connective tissue; T2 indicates tumor invading corpus
spongiosum or cavernosum; T3 indicates tumor invading
urethra or prostate; and T4 indicates tumor invading other
adjacent structures.

14.

e. The extent of lymph node metastasis. The presence

and extent of metastasis to the inguinal region are the most
important prognostic factors for survival in patients with
squamous penile cancer.

15.

e. A single metastasis of only 6 cm. Taken together,

these data suggest that the pathologic criteria associated with
long-term

Surgery of Penile
and
Urethral
Carcinoma
DAVID S. SHARP KENNETH W. ANGERMEIER
QUESTIONS

130

1. Biopsy of a penile lesion provides all of the following

information EXCEPT:

a. requires creation of a perineal urethrostomy.

b. provides for normal sexual function in greater than 70%
of men.
c. is required less often than total penectomy.
d. results in local recurrence rates of less than 10%.

a. confirmation of the histologic diagnosis. !

b. initial assessment of tumor grade.
c. depth of invasion.
d. prognosis.
2. Laser therapy may provide effective treatment for all but which
one of the following lesions?
a.
b.
c.
d.

Invasive stage T2 lesions

Carcinoma in situ
Bowenoid papulosis
Superficial stage Ta penile cancers

3. Techniques that may allow improved delineation of the extent of

superficial penile cancer during laser therapy include all of the
following EXCEPT:
a.
b.
c.
d.

a. using an ultrasensitive gamma ray detection probe.

b. routine inguinal exploration in the absence of radiotracer
visualization.
c. extended pathologic analysis of excised lymph nodes.
d. intraoperative palpation of the wound for abnormal nodes.

9. When compared with the standard groin dissection, the

modified groin dissection has all of the following features
EXCEPT which one?
a. The node dissection excludes regions lateral to the femoral
artery and caudad to the fossa ovalis.
b. The saphenous vein is preserved.
c. The transposition of the sartorius muscle is eliminated.
d. The required incision is longer.

photodynamic diagnosis and autofluorescence.

preparation of the treatment area with 5% acetic acid.
loupe magnification.
frozen section biopsies.

4. Mohs' micrographic surgery provides which of the following?

a.
b.
c.
d.

8. Efforts designed to improve the accuracy of dynamic sentinel

lymph node biopsy include all of the following EXCEPT:

Compromise of long-term local control

Effective therapy for invasive tumors (stage T2 or greater)
Retention of function and anatomic integrity of the penis
Effective therapy for large lesions

10. Which of the following statements regarding radical

ilioinguinal lymphadenectomy is TRUE?
a. The fascia lata remains intact.
b. The saphenous vein may be preserved in the setting of low
volume disease.
c. The rotation of the gracilis muscle is performed to cover the
exposed femoral vessels.
d. The femoral nerve is visualized superior to the iliacus fascia.

All of the following statements regarding conservative surgical

excision for penile carcinoma are true EXCEPT which one?
a. Careful long-term surveillance following surgery is necessary.
b. Frozen section biopsies are usually not needed during these
procedures.
c. Glans defects after tumor excision that are not amenable to
primary closure may be covered with a split thickness skin
graft or a flap of outer preputial skin.
d. Glansectomy and circumcision remove the entire contents of
the preputial cavity.
Successful local control by partial penectomy depends on which
of the following?

11. A pelvic node dissection for male penile cancer should include
all of the following areas EXCEPT which one?
a. Distal common iliac nodes
b. Para-aortic and paracaval node dissection
c. External iliac nodes
d. Obturator group of nodes
12. Which of the following measures may help prevent
lymphedema after a radical ilioinguinal node dissection?

a. Division of the penis at least 2 cm proximal to the gross

tumor
b. Cleanliness of the patient
c. Use of adjuvant chemotherapy
d. Status of inguinal nodes
7. Partial penectomy:
13. 'What is the most frequent site of both stricture disease and
^urethral cancer in the male?

c. Total penectomy
d. Intraoperative ultrasound imaging

a. Pendulous urethra b. Fossa

navicularis c. Bulbomembranous
urethra ; d. Prostatic urethra

, Which of the following statements regarding urethral tumor

recurrence after cystectomy and orthotopic urinary diversion is
FALSE?

. Which of the following is true concerning distal urethral

carcinoma in the male?

a. Prognosis depends on histologic cell type.

b. Penectomy is usually indicated for tumors infiltrating the
; corpus spongiosum.
c. Prognosis is worse than bulbomembranous urethral cancer.
d. Conservative surgical therapy is not effective.
, When a delayed urethrectomy is performed in a male patient
after radical cystectomy, which of the following is necessary to
ensure a complete dissection and decrease the risk of a local
recurrence?
a. Removal of the fossa navicularis and urethral meatus
b. Bilateral groin dissections

a. Preservation of Colles' fascia in the flap dissection

b. Low-dose heparin in the perioperative period
c. A 6-week delay between treatment of the primary tumor
and the node dissection
d. Postoperative bed rest and elastic stockings

a. It seems to occur more frequently than after cutaneous

diversion.
b. Some patients with carcinoma in situ may be successfully
treated with urethral infusion, of BCG.
c. Urethrectomy and cutaneous diversion can often be done
17. Possible causes for female urethral carcinoma include all of the
following EXCEPT:
a.
b.
c.
d.

childhood urinary tract infections.

leukoplakia.
chronic irritation or urinary tract infections.
proliferative lesions such as caruncles.

18. What is the most common histologic type of proximal urethral

cancer in women?

a.
b.
c.
d.

Adenocarcinoma
Squamous cell carcinoma
Melanoma
Transitional cell carcinoma

19. What is the most significant prognostic factor for local control
and survival in female urethral cancer?
a. Anatomic location and extent of the tumor
b. Age at presentation
using bowel from the existing neobladder. d. Surveillance
consists of urine cytology and symptom assessment.

c. Histologic type of the tumor

d. Hematuria
20. Radiation therapy for female urethral carcinoma is most
successful:
a. as a single modality for proximal invasive tumors.
b. when used in conjunction with chemotherapy for low-stage
distal urethral tumors.
c. at controlling distant metastatic disease.
d. at controlling small lesions in the distal urethra.

ANSWERS
1. d. prognosis. Before the administration of therapy, a biopsy is
1 required to provide histologic confirmation of the diagnosis of
: penile cancer and staging information by assessing the depth of
microscopic invasion. Adjacent normal tissue should be included
to evaluate invasion, a crucial differential point with regard to
planning definitive surgery.

16.

a. Invasive stage T2 lesions. Laser therapy has gained

popularity in recent years for the treatment of premalignant
lesions and carcinoma in situ (Bowen's disease, erythroplasia of
Queyrat, bowenoid papulosis) and some stage Ta and small Tl
penile cancers.

17.

c. loupe magnification. Photodynamic visualization and

autofluorescence have been described as aids to guiding frozen
section biopsies during laser therapy of superficial penile cancer,
whereas coating the treatment area with 5% acetic acidoften
results in acetowhite staining of occult areas of squamous cell
carcinoma.

18.

c. Retention of function and anatomic integrity of the

penis.
Mohs' micrographic surgery allows retention of function and
anatomic integrity of the penis without compromising local control
rates in small (<1 to 2 cm) superficial noninvasive and small Tl
tumors and is contraindicated for larger or more invasive lesions.
5. b. Frozen section biopsies are usually not needed during
these procedures. Frozen section biopsies are an essential
component

130

of conservative excision for penile carcinoma to help ensure

complete tumor eradication.

19.

a. Division of the penis at least 2 cm proximal to the

gross tumor. Successful local control by partial penectomy
depends on division of the penis at least 2 cm proximal to the
gross tumor extent.

20.

d. results in local recurrence rates of less than 10%.

Partial penectomy results in a local recurrence rate of 0% to 8%. It
is performed more often than total penectomy, does not generally
require creation of a perineal urethrostomy, and provides for
adequate sexual function in a relatively small percentage of men.

21.

a. using an ultrasensitive gamma ray detection probe.

Techniques reported to increase the accuracy of dynamic sentinel
lymph node biopsy include preoperative inguinal ultrasound
with needle biopsy of any suspicious nodes, routine inguinal
exploration even in the absence of radiotracer visualization,
intraoperative palpation of the wound for abnormal nodes, and
extended pathologic analysis of any excised lymph nodes.

9. d. The required incision is longer. The modified groin

dissection differs from the standard dissection in that
(1) the skin incision is shorter; (2) the node dissection is
limited, excluding regions lateral to the femoral artery and
caudad to the fossa ovalis; (3) the saphenous veins are
preserved; and (4) the transposition of the sartorius muscles is
eliminated.